Healthcare Provider Details

I. General information

NPI: 1265976765
Provider Name (Legal Business Name): DILLON TYLER GIBSON PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2016
Last Update Date: 08/29/2023
Certification Date: 08/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HEALTHSTAR PHYSICIANS 420 W. MORRIS BLVD SUITE 400D
MORRISTOWN TN
37813
US

IV. Provider business mailing address

420 W MORRIS BLVD STE 400D
MORRISTOWN TN
37813-2282
US

V. Phone/Fax

Practice location:
  • Phone: 423-586-7509
  • Fax:
Mailing address:
  • Phone: 423-586-7509
  • Fax: 423-317-8948

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number3169
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number3169
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: